The wrong white crystals: not salt but sugar as aetiological in hypertension and cardiometabolic disease

2Department of Family and Social Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, USA

Correspondence to Dr James J DiNicolantonio; jjdinicol{at}gmail.com

Abstract

Cardiovascular disease is the leading cause of premature mortality in the developed world, and hypertension is its most important
risk factor. Controlling hypertension is a major focus of public health initiatives, and dietary approaches have historically
focused on sodium. While the potential benefits of sodium-reduction strategies are debatable, one fact about which there is
little debate is that the predominant sources of sodium in the diet are industrially processed foods. Processed foods also
happen to be generally high in added sugars, the consumption of which might be more strongly and directly associated with
hypertension and cardiometabolic risk. Evidence from epidemiological studies and experimental trials in animals and humans
suggests that added sugars, particularly fructose, may increase blood pressure and blood pressure variability, increase heart
rate and myocardial oxygen demand, and contribute to inflammation, insulin resistance and broader metabolic dysfunction. Thus,
while there is no argument that recommendations to reduce consumption of processed foods are highly appropriate and advisable,
the arguments in this review are that the benefits of such recommendations might have less to do with sodium—minimally related
to blood pressure and perhaps even inversely related to cardiovascular risk—and more to do with highly-refined carbohydrates.
It is time for guideline committees to shift focus away from salt and focus greater attention to the likely more-consequential
food additive: sugar. A reduction in the intake of added sugars, particularly fructose, and specifically in the quantities
and context of industrially-manufactured consumables, would help not only curb hypertension rates, but might also help address
broader problems related to cardiometabolic disease.

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